Natural history of AIS

• Curve progression
Factors increases curve
progression
1. Curve pattern
• Thoracic
• Double primary
• higher
2. Curve magnitude Greater magnitude,
more sever progression
3. Age of presentation The earlier it show in
life the more the progression is
4. Maturity The major period of progression
is between detection and maturity,
specially growth spurt period.
5. Gender Although female is more
commonly affected, male takes longer to
mature and have longer time to progress.
Progression after skeletal
maturity
• After maturity curves progress much
slower and that depends mainly on curve
magnitude and patient age.
• Curves less than 40 degrees usually don't
progress but not larger ones.
• Below age of thirty they progress more
than above 30 years.
• Adult curves must not progress more than
one degree per year, otherwise if they do
so they need clinical care.
Cardiopulmonary function
• It's more affected in cases of thoracic
curves specially if they are large,
progressive, rigid and when associated
with anomalous chest wall and ribs
 Low back pain
• Studies showed 90-100% incidence,
but genuine pain mainly in more severe
curves of the older patients who got
degerative spondylosis.
• Cosmetic deformity
• Mortality
• Management of AIS
• Aims are:
• Prevent mild deformity from
progression
• Correct an existing unacceptable
deformity
• Treatment options are:
• Exercise
• Electrical stimulation
• Orthopedic orthosis
• Surgery:
– spinal fusion
• Posterior fusion
• Anterior fusion
– Curve correction
• Exercise and electrical
stimulation are best use to
patients who are fit for non-
operative treatment, they didn’t
show real effect on correction but
they maintain muscle tone and
inspire good results in favor of the
outcome.
 :Orthosis
• They are mainly the Milwaukee brace
for the thoracic curves, and the Boston
brace for the lumber curves or their
modulations especially with the recent
advances of orthosis every patient may
have his own designed Brace.
• Braces must have its direct corrective
force directed towards the apical most
deviated and rotated vertebra.
• They always must utilize the 3 point
principle in correction.
• Orthosis found to be of great use to
correct the primary curve especially
during the growth spurt period of
maximum curve progression, but
recurrence had been always reported.
So in its overall end result it prevents
progression until skeletal maturity is
reached where progression is no more
a problem in those minor curves.
• Orthosis are to be used as a full time
treatment (23/24 hours), they also need
frequent intimate follow up by the surgeon
and the physiotherapist to change ,
augment or remove variable padding that
are used to give the maximum corrective
capacity of the orthosis.
• Part time treatment (8/24 hours) is
used in the final steps of treatment before
discarding the orthosis.
 :Surgical treatment
By surgery nowadays we aim at
1. proper spinal curve correction according to the
curve flexibility and its allowable correction
2. Maintenance of correction by internal fixation
that is used to keep the new corrected position
until spinal fusion occurs.
3. Proper fusion of the spine on both sides
posteriorly in the new corrected position and
anterior spinal fusion +/- colpectomy done
whenever indicated.
In such cases where anterior fusion indicated
it's done as first stage surgery and then further
correction and fusion done posteriorly at a later
Curve correction and internal
fixation:
• With the great advances in
surgical technique and methods
of internal fixation, no curve is
beyond full surgical correction,
BUT there are always
limitations against that,
because:
1. Curve must not corrected beyond the
estimated allowable correction according to its
flexibility and the state of its compensatory
curve/s.
2. Extensive curve correction may cause serious
neurological complications, as correction
sometimes pass the allowable limits for cord
stretching, this problem now is avoided by
doing preoperative MRI and the use of
peroperative somatosensory and
somatomotor evoke response potential
study (instead of the previously used
peroperative wake-up test done with the help
of the anesthetist as the patient is awaked
after correction but still he is pain free and
asked to move his lower limbs)
 nowadays internal fixation consists of a
mixture of rods that can be prebent, cross
rods, pedical screws, hooks and
sublaminar wires. All of which can give
perfect curve correction and even
correction of rotation and maintainence of
near normal saggital plane alignment.
• Spinal fusion:
1. The first surgical procedure suggested
and tried for treatment of scoliosis is
posterior spinal fusion, still its one
important part of the surgical treatment
as the corrected spinal position need a
sound and rigid spinal fusion to maintain
it.
2. For spinal fusion during early life
(young children) the remaining ability of
the spinal growth must be taken in
consideration to assist treatment and to
avoid complications as follows:
• One side (convex) fusion may allow
some correction with further spinal
growth at the concave side.
• Early posterior fusion may be associated
with the complication of excessive
anterior column elongation with sever
obliteration or reversal of normal thoracic
kyphosis or lumber hyperlordosis (crank-
shaft phenomenon).
Biomechanics:
• Posterior spinal fusion is
mechanically sound and successful only
in curves of less than 40 degrees in the
saggital or frontal planes (kyphosis
and scoliosis) only otherwise it will fail
with pseudoarthrosis no matter how rigid
it is. In such conditions anterior fusion is
mandatory to keep the corrected
position.
Anterior fusion:
It's indicated for:
• Sever and rigid idiopathic curves
where posterior correction is difficult
or inadequate or posterior fusion is
mechanically unsound.
• Congenital scoliosis.
• Paralytic or spastic scoliosis.
• Severe or congenital kyphosis.
FUSION LEVELS (AREAS):
• Proper selection of the fusion area is
one of the most important aspects of
the surgical procedures, Too short a
fusion will result in lengthening the
curvature and bending of the graft.
Too long a fusion will result in
needless restriction of spinal mobility.
• In general one should fuse the
structural major curve and should
avoid fusing compensatory curve/s.
Three parameters must be
identified in order to choose the
fusion level:
• The end vertebrae of the curve.
• The stable zone.
• The curve pattern "
• Location of end vertebra using plain erect
radiographs, being the one most tilted
towards the concavity of the curve and
beyond which the disc space is
equidistant. Rotation of the vertebra may
aid its identification. Still The end
vertebrae are not necessarily define the
limits of fusion.
• The stable zone serves to assist in
deciding the lower fusion level in order to
keep overall spinal stability.
• The stable zone, as described by
Harrington is the area between two
lines perpendicular to the pelvis,
erected at points of the sacral
pedicles. The first vertebra caudal to
the end of the curve to fall within the
stable zone is the lower end of the
fusion.
• Moe had suggested that the
stable vertebra can be identified
by erecting a line perpendicular to
the sacrum and through its center.
The stable vertebra is the one that
is most nearly bisected by this
line.
• The curve pattern is also of importance and it is
essential to identify the primary curve from a
compensatory one, because only primary curve
should be fused.
• The minimum fusion area is said to include
every vertebra in the primary curve of AIS as
well as all vertebrae that are rotated in the same
direction as those in the primary curve.
• As a general rule, the fusion should extend from
one vertebral body above the superior end
vertebra down to two vertebrae below the
inferior end vertebra for thoracic and
thoracolumbar curves.
• For lumbar curves, the fusion should
extend from one vertebra above the
superior end vertebra down to the
inferior end vertebra if possible to
avoid limitation of spinal movement,
avoid failure of fusion and
pseudoarthrosis and to prevent the
flat back syndrome and pain that is
associated with complete or lower
lumber fusion.
King, Moe classification:
• King, Moe et al (1983) published
the most complete study on the
appropriate fusion levels in
thoracic and double thoracic-
lumbar curves in idiopathic
scoliosis with their own
classification of these curve
patterns on 5 types:
• Combined thoracic and lumbar curves were S-
shaped curves in which both curves crossed a
line drawn vertically from the middle of the
sacrum. The double curves were then divided
into Types 1 and 2.
• Type 1 describes the combined curve in which
the lumbar one is larger in magnitude by 3
degrees or more in the erect AP film and in
which the thoracic curve is more flexible in
forced side-bending films.
• Type 2 describes the combined curve where the
thoracic one is larger and less flexible than the
lumbar one.
• Single thoracic curves subdivided according to
the basic pattern of the thoracic and
compensatory lumbar curves.
• Type 3 is when the lumbar curves have a
plumbline directly centered over the sacrum.
• Type 4 curves the fifth lumbar vertebra is
centered over the sacrum while the fourth lumbar
vertebra was tilted into the long thoracic curve.
• The main difference between Type 3 and Type 4
curves was the length of the thoracic curve and
the pattern of the lumbar compensatory curve.
• Type 5 describes combined
double thoracic curves in which
the first thoracic vertebra was
tilted into the upper thoracic curve
(called a positive first thoracic tilt)
and the first rib was elevated on
the convexity of the thoracic
curve.